CpapforMedicare.com
A division of Nor-Cal Diagnostics
7600 Hospital Drive, Suite E
Sacramento, CA 95823

Phone: 1-866-742-1238
Fax: 1-916-681-0411

CpapforMedicare.com is proud to offer you this service with NO CHARGE and with no obligation.

See if your CPAP or BIPAP equipment and supplies are covered by Medicare by simply completing this form or call-1-866-742-1238.

PLEASE FILL OUT FORM REQUIRED FIELDS ARE NOTED WITH AN *
*First Name:
*Last Name:
*Email Address:
*Phone:
*Best time to call:
*Date of Birth:	Month: January February March April May June July August September October November December Date: Year 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
*Do you plan on choosing Medicare as your primary Insurer?	Yes No Not sure
*Have you ever used or been prescribed CPAP or BIPAP in the past?	No, only during my sleep test Yes, less than 15 months Yes, more than 15 months Yes, more than 5 years
*Comments
By submitting this information, I authorize CpapforMedicare.com to contact me by phone to help determine if my supplies are covered by Medicare.
We are proud to offer you this service for no charge and with no obligation. We value your privacy. View our privacy statement.